In keeping with our goal to keep you informed about legislative activities that ABC and the O&P Alliance are undertaking as well as those championed by the American Orthotic and Prosthetic Association (AOPA), we would like to share the following article from AOPA.

On July 7, 2020 the Centers for Medicare & Medicaid Services (CMS) released the new implementation dates for the Medicare prior authorization of six lower limb  prostheses codes (L5856, L5857, L5858, L5973, L5980 and L5987). Phase I has been under way in California, Michigan, Pennsylvania and Texas (one state in each of the four DME MAC jurisdictions) since September 1, 2020. Phase II, involving the remaining states and terrorties in each the four DME MAC jurisdictions, will begin for claims with a date of service on or after December 1, 2020. In anticipation of the December 1 date the DME MACs will begin to accept prior authorization requests on November 17, 2020.

To help prepare for Phase II here is quick recap of the prior authorization process:

• Complete the prior authorization request (PAR) coversheet for LLP from your DME MAC.
• Submit the PAR coversheet and all supporting documentation (the Standard Written Order and all records which support medical necessity) to the DME MAC for review.
• Within 10 business days you will receive either an affirmative or non-affirmative decision and a unique tracking number (UTN).
• If you received an affirmative PAR, you may submit your claim for payment, be sure to include your UTN on the claim.
• If you received a non-affirmative PAR, you may attempt to fix any errors and resubmit your PAR, and there is no limit to the number of times you may resubmit the PAR.

When preparing for future prior authorization requests and claim submissions for L5856, L5857, L5858, L5973, L5980 and L5987, please be advised of the upcoming Pricing, Data Analysis and Coding Contractor (PDAC) coding verification requirement. On June 26, 2020, the DME MACs and PDAC released a joint announcement which stated that, effective for claims with dates of service on or after January 1, 2021, the only products which may be billed using codes L5856, L5857, L5858, L5973, L5980 and L5987 are those for which a written Coding Verification Review has been made by the PDAC and is listed on the PDAC Product Classification List.

Questions? Contact American Orthotic and Prosthetic Association staff, Joe McTernan at jmcternan@AOPAnet.org or Devon Bernard at dbernard@AOPAnet.org.